Infection Control Program Deficiencies: EBP, Hand Hygiene, and Catheter Storage
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control program. The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents with wounds or indwelling devices, as required by both facility policy and CDC guidance. For example, one resident with venous and arterial ulcers and another with a surgical wound and positive wound cultures for pseudomonas and E. coli were not placed on EBP at admission, and there were no physician orders for EBP for these residents. Staff interviews revealed inconsistent understanding and application of EBP, with decisions often based on wound drainage rather than the presence of wounds or devices, contrary to policy. Additionally, the facility was unable to provide a policy related to EBP when requested. Observations also revealed improper storage of urinary catheter drainage bags. In one instance, a resident's large urinary catheter drainage bag was found hanging from a shower handrail in a shared bathroom, with urine present in the tubing and the bag near other stored items. Staff interviews confirmed that the bag should have been stored in a plastic bag in a drawer, not on the handrail, and the facility's urinary catheter care policy did not address storage of drainage bags when not in use. Further deficiencies were noted in hand hygiene and staff grooming practices. During medication administration, an LPN failed to perform hand hygiene before and after glove use and between resident care activities, despite acknowledging the requirement. Another LPN was observed with long, colored fingernails extending past the fingertips, which is not compliant with CDC recommendations for hand hygiene and infection control. Additionally, a CNA was observed entering and exiting a resident's room with a wound without appropriate PPE, and PPE caddies were not consistently available outside resident rooms as required for EBP implementation.